Provider Demographics
NPI:1548396849
Name:PETERSEN, SANDRA (DNP,APRN, GNP-C)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DNP,APRN, GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6827 DEL NORTE LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-2552
Mailing Address - Country:US
Mailing Address - Phone:214-213-4726
Mailing Address - Fax:
Practice Address - Street 1:6800 WEST LOOP S
Practice Address - Street 2:SUITE 180
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-4528
Practice Address - Country:US
Practice Address - Phone:713-981-6125
Practice Address - Fax:713-664-7656
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX596367363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB131306Medicare PIN